Summary: The authors conducted a secondary analysis of the multicenter Ohio Pediatric Asthma Repository (OPAR) study to look for associations between use of ipratropium and IV magnesium with outcomes of children hospitalized with acute asthma exacerbations. In the original OPAR study, children 2-17 years old admitted to one of six Ohio Children’s hospitals (Akron, Cincinnati, Dayton, Nationwide, Toledo, and Rainbow Babies) were prospectively enrolled in a database. Children admitted from December 2012 to September 2013 who received continuous albuterol in the initial inpatient location were included in the analysis. The primary outcome was duration of continuous albuterol and the secondary outcomes were time to Q4 hour albuterol and length of stay (LOS). In Cox proportional hazards models, magnesium use was associated with longer duration of continuous albuterol but ipratropium use was not, even after adjusting for demographics, hospital, treatment location, or respiratory failure (as a marker of illness severity). Magnesium was also associated with longer time to Q4 and LOS, while ipratropium was only associated with longer time to Q4. What are the key strengths of the article?This is the first large study using a statewide database to look at ipratropium and IV magnesium use for children with severe asthma exacerbations in the inpatient setting.

Are there any limitations or flaws in the article?Only variables existing in OPAR could be examined in this secondary analysis. Additionally, only one marker of illness severity was used. Inclusion of other markers (such as asthma severity scores) may have reduced the significance of magnesium’s association with prolonged outcomes, since sicker patients may have preferentially received magnesium. Despite adjusting for hospitals, different asthma protocols may have altered the outcomes studied. Finally, there was no data available on medication dosing, timing, or adverse events. What is the major takeaway message?Magnesium was associated with worse results in all three outcomes analyzed (duration of continuous albuterol, time to Q4, LOS), while ipratropium was only associated with longer time to Q4. However, limitations of the study prevent us from drawing conclusions about the efficacy of either drug. There is currently wide variation reported by pediatric floors and ICUs across the country on use of ipratropium and magnesium. Prospective RCTs are needed to investigate the effect of ipratropium and IV magnesium on outcomes for children hospitalized with asthma exacerbations. Describe how this article should impact our practice:As the authors mentioned, this article should be viewed as “hypothesis generating” and does not offer sufficient evidence to change practice. Pediatricians should be aware that there is a lack of evidence on the efficacy of ipratropium and IV magnesium to treat hospitalized asthmatics and use discretion when deciding whether or not to utilize these therapies.